My three year old daughter was diagnosed five months ago, we are having difficulty controlling her blood sugars, and her diabetes team has never done any tests or given us answers. She was taking Regular with NPH insulins, but, after a couple of months, the Regular was not taking effect until the NPH was. Her blood sugar would go super high and then go super low after a few hours. When we went to her pediatric diabetes clinic appointment, we brought up this problem, and the team told us they weren’t sure what the problem could be, so we all decided just to keep the tightest schedule possible with her shots. This ended up not doing much good, so we were given Humalog in addition to the NPH and Regular. However, the Humalog takes about two hours to take effect, and her blood sugar will usually go up over 400 mg/dl [22.2 mmol/L] until it does. What can we do?

It isn’t likely that the Humalog would take so long to work in a very young child. It’s more likely that you are not giving enough Humalog to cover her carb intake.

Our approach would be to do some pre and postprandial blood glucose testing and couple this with every few hours overnight for three or four days in a row to define when insulins are working and then regroup with the data to analyze it all. We frequently see an NPH peak around three to four hours and then it’s gone by five to six hours so we used to use overlapping doses of NPH at breakfast, lunch, dinner and bedtime before Lantus (insulin glargine) became available. Now, we usually use Lantus at 10:00-11:00 pm to avoid middle of the night insulin peaks and provide more consistent pre-breakfast coverage, with Humalog pre-breakfast, Humalog plus NPH pre-lunch, Humalog pre-afternoon snack, Humalog at dinner and Lantus at bedtime for our youngest patients with good results.

However, all this should be based upon actual blood glucose information for your own child and not rules of when things work or don’t work. There are some colleagues who use Lantus at breakfast, some who use it at dinnertime, etc. All based upon actual blood glucose profiles. Please consult with your daughter’s diabetes team before making any changes.

SB